Which veins are suitable for ultrasound guided foam sclerotherapy (UGFS)?

As you will understand from our section on ‘how foam sclerotherapy works‘, veins that are most suitable for treatment using ultrasound guided foam sclerotherapy (UGFS) are those that are over 1 mm in diameter but less than 3 mm in diameter. It can be used in veins slightly larger than 3 mm in diameter, but as the technology stands at the moment, patients should be aware that the long-term results get worse and worse the larger the veins are and the higher the risk is of inflamed lumps, discomfort and discolouration.

In addition, ultrasound guided foam sclerotherapy (UGFS) is not very effective in the large lumpy surface veins (“varicosities”) that once again are usually much greater than 3 mm in diameter. In these veins foam often causes hard red lumps with long-term brown staining.

However there are situations where ultrasound guided foam sclerotherapy (UGFS) comes into its own and, sometimes, is the only effective treatment that can be performed. These situations include:

Feeding veins – this is the name given to the small diameter veins that feed into patches of thread veins (or spider veins). Although in the past cosmetic doctors and nurses have tried to solely treat thread veins (or spider veins) on the legs with injections, laser or other techniques, research from 2001 has shown that the thread veins (or spider veins) are in fact being fed by feeding veins in approximately 89% of cases. These feeding veins may be visible on the surface when they are called “reticular veins” or maybe deep to the skin and therefore invisible in which case they can only be seen with an ultrasound scan. For successful treatment of the thread veins, it is essential to treat the feeding veins first. The optimal way to do this is ultrasound guided foam sclerotherapy (UGFS) which not only treats the feeding veins but can often spread into the thread veins (or spider veins) treating these as well.

Neovascular tissue – when veins used to be operated on by the older type of surgeon, the veins were tied and cut through surgical incisions. Of course the body did not realise that surgery was being performed – it responded as if the body had been damaged. As such the body tries to heal, and this means that as part of the healing process, the ends of the cut veins start growing across the damaged area to find other damaged veins. The result of this is a network of small veins throughout the scar tissue, none of which have valves and therefore all of which cause the same problem that was initially operated on – recurrent varicose veins. Neovascular vessels are very small in diameter although there may be a great number of them. As such they are ideal to be treated by foam sclerotherapy which can spread through a large number of them completely destroying them.

Re-revascularised veins – when a truncal vein such as the great saphenous vein (GSV) or small saphenous vein (SSV) is stripped away, the body tries to repair the damage. Just as with neovascular tissue, the ends of the veins, including the small branches or tributaries that used to come off the vein that were stripped away, start producing small veins that grow into the damaged tissue. Over months to years, these can connect up again causing a “revascularised vein”. When this first forms, it is a series of small diameter veins. If left long enough, these can connect together forming a large “re-revascularised vein”. As with the neovascular tissue, this new vessel wall does not have any valves in it and as such causes the same problem that the initial varicose vein had – causing recurrent varicose veins or any other venous problem that was present to recur. Ultrasound guided foam sclerotherapy is perfect to treat small vessels that are forming in the revascularisation process, although if these have started to join together into a larger revascularised vein, it may be that the diameter is too large and endovenous laser ablation (EVLA) or radiofrequency ablation (RFA) may be the better option.

Veins under ulcers or hardened skin – if venous reflux has progressed past aching of the legs, swelling of the ankles and/or varicose veins, the skin around the inner part of the lower leg can become hardened, red or brown, or even breakdown into a venous leg ulcer. Treatment of the truncal veins or perforating veins that have caused this is usually by endovenous laser ablation (EVLA), radiofrequency ablation (RFA) or transluminal occlusion of perforators (TRLOP) all of which stop the major problem. However this often leads to a network of small incompetent veins under the hardened skin or ulcer which cannot be treated through this abnormal surface. In such cases, ultrasound guided foam sclerotherapy (UGFS) is an ideal way of treating these veins, usually with very good results.

Vulval or vaginal varicose veins – varicose veins in the vulva or vagina are usually found in women who have had at least one baby by natural (vaginal) birth. They almost always have varicose veins inside the pelvis, caused by the valves giving way in the ovarian or internal iliac veins in the pelvis. As with most areas that foam is used in, these veins pelvic veins need to be treated first by coil embolisation and then the foam sclerotherapy can be used to treat the veins in vulva and vagina.

As a finishing procedure to varicose vein surgery – many people with severe varicose veins, particularly if the varicose veins are recurrent or very widespread, have the major same problem treated successfully with pelvic vein embolisation, endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ambulatory phlebectomies and/or transluminal occlusion of perforators (TRLOP). All of these techniques target certain veins and effectively destroy them. However in severe cases where the veins are very widespread, particularly if there are scars from previous venous surgery, then these techniques can leave behind many small veins that are not visible on the surface but which will all start to try to repair themselves as part of the healing process. In these cases, it has been found that the injection of ultrasound guided foam sclerotherapy into these little veins after all of the major veins have been treated, stops them from trying to reconnect to each other and reduces the risk of veins growing back again causing recurrent varicose veins or recurrent venous problems.

In summary, ultrasound guided foam sclerotherapy (UGFS) is a very versatile technique for treating a multitude of small veins and recurrent veins. It is rarely a treatment to be used by itself but, when used in combination with other endovenous techniques, can produce excellent results.